An- Najah National University

Faculty of Graduate Studies

The Influence of Backpacks on Students backs A

Cross-Sectional Study of Schools in Tulkarm District

By
Alaa` Osaid khalil AL-Qato

Supervisor
Dr. Khalil Issa
Co-Supervisor
Prof. Gassan Abu-Hijleh

This Thesis is submitted in Partial Fulfillment of the Requirements

for the Degree of Master of Public Health, Faculty of Graduate
Studies, An-Najah National University, Nablus, Palestine.
2012
 iii

Dedication

I dedicate my efforts in this study to my father Osaid

(may Allah, almighty, bless his soul) and my beloved
mother Mariam, brothers, sisters and all my family
members for their continuous encouragement
throughout the course of my research.

Alaa` Osaid AL-Qato

 iv

Acknowledgment

It is not possible to credit everyone who has contributed to the

success of this research. However, I would like to give particular
Recognition to those who helped and guided me through this study.

I would like to give Special Thanks with deepest appreciation to

my supervisors Dr. Khalil Issa and Prof.Ghassan Abu-Hijleh for the
valuable discussions, effort, patience, encouragement and their
continuous support throughout this study.

Thanks are also due to the Palestinian Ministry of Education,

Directorate of Education and School Headmasters and students at
Tulkarm district for their help in sample collection. Thanks are also
due to Dr. Jihad Abdallah for his kind help and assistance in
statistical analysis.

I shall never be able to express adequately my acknowledgment

to all my supportive friends, who were very cooperative and helpful.
Sincere thanks, appreciation, and love go to all my family members,
especially to my mother, for their patience, encouragement, and
endless support during my graduate study.
 v

The Influence of Backpacks on students Backs: A

Cross-Sectional Study of schools in Tulkarm District.
-

Declaration

The work provided in this thesis, unless otherwise referenced, is the

researcher's own work, and has not been submitted elsewhere for any other
degree or qualification.

Student's name: :

Signature: :

Date: :
 vi
List of Abbreviations
DP: Dorsal Pain
L.B.P: Low Back Pain
C.C.A: Cranio Cervical Angel
C.V: Cranio Vertebral
H.O.N: Head on Neck
C.V.A: Cranio-vertebral Angle
T.F.L: Turn Forward lean
L.A: lordosis Angle
M.R.I: Magnetic Resonance Imaging
C.G: Center of Gravity
A.O.T.A: American Occupational Therapy Association
A.P.T.A: American Physical Therapy Association
A.C.A: American Chiropractic Association
S.I.L: Stander Institution of Israel
A.A.P: American Academy of Pediatrics
H.O.N.T: Head on Neck or Trunk
M.S.D: Musculoskeletal Disorder
A.I.S : Adolescent Idiopathic Scoliosis
C.O.P: Center of Pressure
B.W: Body weight
M.O.H: Ministry of Health
M.O.E.D: Ministry of Education
 vii
Table of Contents
No. Contents Page
Dedication iii
Acknowledgment iv
Declaration v
List of abbreviations vi
Table of Contents vii
List of Tables ix
List of Figures x
Abstract xi
Chapter One: Introduction 1
1.1 Anatomy of vertebral column 2
1.2 Backpack syndrome 11
1.3 Backpack health problem 13
1.3 .1 Back pain in student 13
1.3.2 Back pain Related with Backpack 14
1.3.3 Carrying school bag and musculoskeletal symptoms 16
1.3.4 Design and portage of back pack 17
1.4 Significance of study 18
1.4.1 Purpose of study 19
Chapter Two: Literature Review 21
2.1 International Studies 22
2.2 Regional Studies 32
Chapter Three: Methodology 33
3.1 Study Design 34
3.2 Sampling 35
3.3 Inclusion Criteria 38
3.4 Exclusion Criteria 38
3.5 Questionnaire 39
3.6 Research Questions 41
3.7 Data Analysis 42
3.8 Ethical consideration 42
3.9 Limitations of study 43
Chapter Four: Results 44
4.1 Descriptive Analysis of the Study Sample 45
4.2 Analytical findings 52
Factors Associated with Development of
4.2.1 52
Musculoskeletal Pain while Carrying School Bag
Factors Associated with occurrence of fatigue while
4.2.2 55
carrying school bag.
 viii
No. Contents Page
Chapter Five: Discussion, Conclusions and
58
Recommendations
5.1 Discussion 59
5.2 Conclusions 66
5.3 Recommendations 67
References 70
Appendixes 79
 ix
List of Tables
No. Table Page
The total numbers of students in all the grades that
Table (3:1) 36
study includes.
The distribution of schools according to the
Table (3:2) 37
region.
The distribution of students according to body
Table (3:3) 40
mass index groups.
Table (4:1) Distribution of students according to grade level. 45
Distribution of students according to the ratio of
Table (4:2) 46
school bag weight to body weight.
Distribution of students based on frequency of
Table (4:3) occurrence of musculoskeletal pain in general and 48
musculoskeletal pain due to carrying school bag.
Distribution of students according to their
Table (4:4) 49
behavior related to school bag.
Averages of student age, weight, height, BMI, bag
Table (4:5) weight (empty: and full), and bag weight to 51
student weight ratio by grade and gender
Significance of factor effects on Occurrence of
Table (4:6) 52
pain.
Relative risk of various levels of the factors
Table (4:7) investigated for relation with musculoskeletal pain 53
while or after carrying school bag
Significance (P values) of factor effects on
Table (4:8) 55
occurrence of fatigue while carrying school bag.
Relative risk of various levels of the factors
Table (4:9) investigated for relation with fatigue while 57
carrying school bag
 x
List of Figures
No. Figure Page
Figure (1:1) The spinal column diagram. 5
Figure (1:2) Normal curves of the spine. 6
Figure (1:3) Abnormal curves of the spine. 7
Figure (1:4) The Muscles of the vertebral column. 8
Figure (1:5) The spinal cord. 9
Figure (1:6) The spinal Nerves. 10
Figure (4:1) Methods of transport to arrive to school. 47
Figure (4:2) Time it takes students to get to school. 47
Rest time students take because of carrying
Figure (4:3) 49
school bag
Distribution of students according to the way
Figure (4:4) 50
they carry school bag.
 xi
The Influence of Backpacks on Students backs A Cross-Sectional
Study of Schools in Tulkarm District
By
Alaa` Osaid khalil AL-Qato
Supervisor
Dr.Khalil Issa
Co-Supervisor
Prof.Gassan Abu-Hijleh
Abstract

There is an ongoing concern regarding the weight of childrens

schoolbags and the negative consequences of such heavy loads on the

musculoskeletal pain and developing spine.

This study investigated the weight of school bag (ratio) and

musculoskeletal symptoms related to school bag carriage on primary and

secondary schools in Tulkarm district. The purpose of the present study

was to determine the relationship between musculoskeletal pain and/or

fatigue and school bag carriage in Tulkarm schools. A cross sectional

study, using random sampling method was conducted during spring 2009.

800 students (males and females) grades 3-9 correctly filled out a

questionnaire with closed-ended questions. Each students weight and full

backpack weight were measured. The results revealed that the mean full

schoolbag weight was 5.267 kg; the mean percentage of full school bag to

body weight was 12.3%. Also, 73% of the students had a loaded bag

weight 10% of body weight, For pain related to carrying schoolbag;

47.8% of students had shoulder pain, 21.6% had lower back pain, and

18.2% had neck pain .

 xii

However, with regard to the grade, time to arrive to school, ratio of

the bag weight to body weight, and right-left swaying, it was showed that

they had significant relationships with occurrence of musculoskeletal pain,

while residence, transport, and carry method had no significant relationship

(P > 0.10) with occurrence of pain. Also; gender, grade, time to arrive to

school, ratio of bag weight to body weight, carry method and right-left

swaying were significantly associated (P < 0.05) with occurrence of

fatigue, while residence and transport had no significant relationships (P >

0.10) with occurrence of fatigue . Carrying a backpack weighing >10% of

body weight appeared to be too heavy to maintain posture for students.

It is recommended that a school bag should be limited to no more

than 5-10% of a students body weight and work towards affording e-book
for each student should be taken seriously. There is always a need for

further research in this area and more in-depth studies to identify risk

factors for bodily pains in school children.

 1

CHPTER ONE
INTRODUCTION
 2
CHPTER ONE
INTRODUCTION

It was and still is of great concern the relation between back pain and

school bags. In this study, we are also concentrating on the issue of

children health through their developmental years in regards of holding

school bags on their backs and causing what is called (backpack

syndrome). We assume that the parents and teachers are not so much aware

of the risks of such a problem. We are trying through this study to come to

a conclusion that aids alleviation of this bag burden and prevent the

progression of its implications upon school children.

In order to better understand abnormalities or health problems related

to spine in children we need to be aware of some basic spinal anatomy.

1.1 Anatomy of vertebral column

The back is an intricate structure of bones, muscles, and other tissues

that form the posterior part of the trunk from the neck to the pelvis. The

centerpiece is the spinal column, which not only supports the upper bodys

weight but houses and protects the spinal cord the delicate nervous

system structure that carries signals to control the bodys movements and

convey its sensations. Stacked on top of one another are more than 30

bones the vertebrae that form the spinal column, also known as The

Spine. Each of these bones contains a roundish hole that, when stacked in
register with all the others, creates a channel that surrounds the spinal cord
(72).
 3

The bones or vertebrae that make up the spinal column are not

stacked directly on top of each other. There are spaces between them that

are maintained by round, spongy pads of cartilage called intervertebral

disks. These disks and the spaces between the bones that they fill, give the

back flexibility. The disks act much like shock absorbers throughout the

spinal column to cushion the bones as the body moves. Bands of tissues

called ligaments and tendons hold the vertebrae in place and attach the

muscles of the back to the spinal column. Small nerves called roots enter

and emerge from the spinal cord through spaces between the vertebrae (3.73).

The spine has three major components (1):

The spinal column (i.e., bones and discs).

Neural elements (i.e., the spinal cord and nerve roots).

Supporting structures (e.g., muscles and ligaments).

Spinal column.

The spinal column is part of the axial skeleton, in adults it consists of

26 bones; considering the sacrum and coccyx each as one bone (Figure1:1).

The primary functions of the spinal column include (2):

Providing a column of support, bearing the weight of head, neck, and

trunk.

Ultimately transferring the weight to the appendicular skeleton of the

lower limbs and protecting the spinal cord.
 4

Helping to maintain an upright body position, as in sitting or standing.

Providing flexibility of motions.

The spinal column is divided into cervical, thoracic, lumber, sacral

and coccygeal regions (2):

Seven cervical vertebrae constitute the neck and extend inferiorly to

the trunk.

Twelve thoracic vertebrae from superior portion of the back; each

articulates with one or more pairs of ribs.

Five lumber vertebrae form the inferior portion of the back;

The fifth articulate with sacrum, which in turn articulates with the

coccyx. The cervical, thoracic, and lumber regions consist of

individual vertebrae.

During development, the sacrum originates as a group of five

vertebrae and the coccyx begins as three to five very small vertebrae. In

general, the vertebrae of the sacrum are completely fused by age 25-30
year. Ossification of the distal coccygeal vertebrae is not complete before
puberty, and thereafter fusion occurs at a variable pace (2).
 5

Figure (1:1): The spinal column diagram

Spinal curvatures

The spinal column is neither straight nor rigid. A lateral view shows

four spinal curves (Figure 1:2): the cervical, the thoracic, the lumber, and

the sacral. In the fetus, there is only a single anteriorly concave curve. At

approximately third postnatal month, when the infant begins to hold its

head erect, the cervical curve develops. Later, when the child stands and

walks, the lumber curve develops. The cervical and lumbar ones are

anteriorly convex. Because they are modifications of the fetal position, they
 6

are called secondary curves. The other two curves, the thoracic and the

sacral are anteriorly concave. Since they retain the anterior concavity of the
(1)
fetus, they are referred to as primary curves the cervical curve develops
as the infant learns to balance the head upright. The lumber curve develops

with the ability to stand. Both compensations become accentuated as

toddlers learn to walk and run. All four curves are fully developed by the
(2)
age of 10 years .

Figure (1:2): Normal curves of the spine

Several abnormal distortions of spinal curvatures (Figure 1-3) may

appear during childhood and adolescence. Hyper kyphosis is an

exaggerated thoracic curvature, Hyper lordosis is an exaggerated lumber

curvature and scoliosis is an abnormal lateral curvature (2). When we stand,

the weight of our body must be transmitted through the spinal column to
the hips and ultimately to the lower limbs. Yet most of our body weight lies

anterior to the spinal column.

 7

Figure (1:3): Abnormal curves of the spine

Muscles and ligaments of the Spinal column

The spinal column (Figure1:4) is covered by superficial back

muscles, such as Trapezius and latissimus Dorsi, and deep layer ones such

as Semispinalis, longus Capitis, oblique and rectus muscles, all of which

function together to move the spine (2). These muscles also provide support
for the spine, allowing us to comfortably carry out our everyday activities.

Back muscles can be grouped into three main categories. First, the extensor

muscles allow us to stand up straight. Secondly, the flexor muscles allow

us to bend forward. Finally, the oblique muscles enable us to rotate from

side to side and keep everything stable and aligned.

Ligaments and tendons are fibrous bands of connective tissue that

attach to bones. Ligaments connect two or more bones together and also

help to stabilize joints. Tendons attach muscle to bone. They vary in size

and are somewhat elastic. The system of ligaments in the vertebral column,

combined with the tendons and muscles, provides a natural type of brace to

help protect the spine from injury. Ligaments keep a joint stable during rest

and movement. Further, ligaments help to prevent injury from hyper-

 8

extension and flexion movements and if the muscles and ligaments are

stretched or strained it can cause pain.

Figure (1:4): The Muscles of the vertebral column

Spinal cord

The spinal cord is a cylindrical structure that is slightly flattened

anteriorly and posteriorly, Figure (1:5). It begins as a continuation of

medulla oblongata, the inferior part of the brain stem, and extends from the

foramen magnum of the occipital bone to the upper level of the second

lumbar vertebra. The length of an adult spinal cord ranges from 42 to 45

cm (1).
 9

The spinal cord has two main functions: it controls many reflex

activities of the body and it transmits information back and forth from the

nerves of the peripheral nervous system to the brain (3).

Figure (1:5): spinal cord

 10

Spinal nerves figure (1:6) are classified as mixed nerves; they

contain both afferent (sensory) and efferent (motor) fibers. There are 31

pairs of spinal nerves, each identified by its association with adjacent

vertebra (2).

Figure (1:6): spinal nerves

 11

1.2 Backpack syndrome

Backpack

Back packs are used by the school-age students to carry school

books, supplies, other articles, and equipment. Students often carry

between 10 and 40+ lb (4.5-18 kg) on their backs to and from school and

between classes (4).

Etiology

A- Back packs can be threatening to the health of students when they

are too heavy, packed, lifted, or worn improperly, previous factors are
usually combined. Human beings have used their backs for centuries to

carry heavy loads. The school students carry their backpacks in a variety of

positions that can adversely affect them physically by affecting their spinal

column and other bone structures that are not fully developed (4).

B- Wearing backpacks alters the mobility of spine, leading to passive

movement (involuntary movement from an outside force), which is a risk
(5)
factor for back pain . Low back pain during the adolescent years can
result in low back pain in adulthood (4).

Characteristics

1. Poor posture.

2. Headache, fatigue, or both.

3. Low back pain that may become chronic.

 12

4. Discomfort, pain, or both in the shoulder and neck.

5. Muscle spasms of neck and shoulders.

6. Pressure sores or blisters of the back or shoulders from straps or

inappropriately packed objects (4).

Healthy concerns.

1. Adverse Effects (4):

a. May cause long-term health problems resulting from neck,

shoulder and back pain, as well as fatigue.

b. Poor posture and pain resulting from leaning forward with neck

thrust forward.

c. Shoulder and arm strain from dragging back pack.

d. Strain and stress on one side of the body curved by using only one
shoulder strap.

e. Numbness and tingling in the upper arm area due to straps

pressure.

2. Schoolbag risk factors (4):

Risk factors for adverse effects on the spine include:

a. A schoolbag that weighs more than 10 per cent of the childs weight.

b. Holding the bag in one hand by its straps.

 13

c. Carrying the bag over one shoulder.

d. An incorrectly packed backpack.

e. An incorrectly fitted backpack.

1.3 Backpack health problems

1.3.1 Back pain in students

Back pain is a common affliction and a leading cause of disability in

adults, but only recently has back pain been documented in large scale
(6)
studies in children and adolescents . Back pain in students is a serious

concern. For adult, the strongest predictor of future back pain is previous

back pain, so having back pain in childhood could have serious future
(6)
implications . The prevalence of non specific back pain increases from

10% in the preteen age years to 50% in 15 to 16 years old, children and

adolescents rarely seek medical care for back pain and parents are not

always aware that their children are experiencing back pain or other

musculoskeletal pain or discomfort (6).

Studies of back pain in children have implicated numerous causative

(7) (8)
factors, including heavy back pack and psychosocial issues . Both

sedentary life styles and involvement in competitive sports are associated

with higher incidence back pain (6, 9).

Ergonomics awareness and posture training may offer an important

preventive approach to back pain and should therefore be incorporated into

 14

physical education programs. It is important for students to learn about the

structure of spine and back care. Recognizing the natural curves of the

normal spine and learning to maintain the natural curves while lifting and
sitting may help reduce the risk of musculoskeletal disorder (MSD) (6).

Posture and back care are not currently emphasized in education

curricula, and posture education may not be included in the standards

(6)
required by individual state , however back care education can be

improved when a physical education teacher or physical therapist is present

and when classroom teacher is also present subsequently reinforcing the

training.

1.3.2 Back pain related with backpack

In recent years, more attention has been paid to back pain in

children, partly because it has lately been found to be more prevalent than

previously thought. Recent studies suggested that 10-30% of healthy

children experience back pain, especially low back, by their teenage years
(10)
. One common suspect for back pain in children is the school backpack,

which has also received a greater deal of attention in the past few years (10).

A study in Italy found that the average load of backpack was 22% of the

childs weight and that 1/3 of the children surveyed carried excess of 30%

of their body weight at least one time per weak, their point prevalent for

reporting back pain was nearly 16%. With life time prevalence is estimated
to be 48% (11).
 15

In Australia, over 20% of students aged 12-18 years had low back

pain related to backpack use. The "U.S Consumer Product Safety

Commission" reported that over 7000 emergency room visits in 2001 were
related to students wearing backpack and handling books. With statistics in

mind, researchers have recently begun to investigate the variables involved

with children; backpack, posture and low- back pain (12).

Researchers examined changes in spinal posture of 985 Australian

adolescents aged 12-18 who carried backpacks at school, researchers found

significant differences in the students cranio-vertebral angel (CVA) or

forward head angel when they wore loaded backpacks as compared to

wearing empty backpacks. This forward head posture was apparent even

when backpacks were positioned over both shoulders (12).

The largest differences in the students cranio-vertebral angel or

forward head angel were seen in younger students, suggesting that as the

spine matures it develops deferent postural responses and adaptation to the

load (12).Also, it was found that the cranio-vertebral angel was increased for

students age 13-16 who carried backpack for at least 5 minutes duration
(30, 12)
and that weighted 15% of their body weight .Some researchers found

that younger students aged 12 to 14 years who carried backpacks greater

(13)
than 6% of their body weight were at greater risk of low back pain .

Organizations such as the American Occupational Therapy Association

(AOTA, 2003), American Physical Association (APTA, 2003), and

American Chiropractic Association (ACA, 2003) have focused on

 16

prevention efforts such as educating parents, youths and school

administrators about this issue.

Although public health efforts globally endorse decreasing the

present weight of student backpack, recommendations as to the percentage

to body weight differ among organizations. The AOTA and APTA

recommended wearing backpack no more than 15% of student body weight

as this is a feasible yet prudent goal and it is better to be limited at 10% (12).

The ACA suggested wearing backpack no more than 5-10% of child's body

weight secondary to the danger of excessive load placed upon maturing

spine (12).Most importantly, students need to develop an awareness of these

issues in order to monitor their own practices.

1.3.3 Carrying school bag and musculoskeletal symptoms

Parents, students, teachers and clinicians have expressed concern

about school bags. Problems related to school bags include the weight of

the bag, how it is packed, and how it is carried. In this section we explain

the risk factors associated with the school bag use.

References to children of school bag on the web sites of the

American Academy of Pediatrics (AAP), (AOTA) and (APTA) revealed a

wide range of symptoms and complaints associated with back pack.

Children report discomfort, aches, and pain in their necks; shoulders and

back associated with a heavy school bag. Muscle weakness, tingling in the
arms, stooped posture, and headaches have also been reported as associated
 17

with carrying a heavy school bag. Children are not alone in this

problematic situation; parents and teachers are concerned and describe

signs of pressure; those signs are reported at the shoulder girdle caused by
(14)
bags straps or at palms during carrying a trolley . Many researchers
(15,
found that carrying backpacks affected posture and balance of students
16, 17)
. Carrying a heavy bag causes students to lean forward in order to

balance their body against the bags weight, this compensation has a

greater effect when the subject carries a bag that weighed 15% of the body

weight, the heavy bag makes it easier to fall and distort the natural curves

in the middle and lower backs, causing muscle strain and irritation to the
spine joints, the rib cage, and causes rounding of the shoulders (14).

1.3.4 Design and portage backpack.

Students wear /carry backpack in a variety of motions and positions,

including walking up and down stairs, entering vehicles, riding bicycles,

and walking over rough surface. Backpacks with two shoulder straps are
the more common design.

However, students sometimes suspend the bag from one shoulder,

dispensing with the use of the second strap. A comparison of double and

single- strap bags found that wearing a double straps bag and using both

straps was generally superior in terms of preference, practicality, comfort,

balance and ease of walking and producing less neck discomfort and
(6)
shoulder pressure and lower perceived exertion . Carrying school bag in
 18

one hand has been reported to be the most inefficient method, as it requires

an energy expenditure of more than twice that of the back pack method (6).

While examining the school bags design, we should have a look at

(14)
three components :

a. The back of the bag should be firm and padded to prevent and
adequately reduce the pressure on the childs back, and the level of the
back should be adjusted to the child back.

b. The straps should be padded and adjustable.

c. The handles should be smooth and comfortable for handling without

any rough edges or sharp angles.

The bag size is another element, according to Stander Institution of

Israel (SIL) it should be as the following:

a) Height: 40 2cm (16 3/4 in)

b) Width: 29 1cm (11 1/2 in)

c) If there is waist or hip belt, it should be at least 50mm (2in) wide,

strap: 30 mm (1.25 in) wide or more and light weight materials are
preferred (14).

1.4 Significance of study

Children often are seen tottering to school with heavy school bags
that can negatively influence their health especially with this transitional
period of life to adulthood over many years.
 19

We can clearly notice the growing weight of school bags and its

effects on health of the children that has become a matter of serious

concern for every parent, schools, and authorities. They have also been
expressing their concerns of the issue but nothing is being done to resolve

this problem.

We find it of equal importance too to determine childrens opinion

on their individual daily school bag load. Up to my knowledge, no study in

Palestine has evaluated the influence of backpack on students backs

before, for these reasons we were encouraged to perform this study.

1.4.1 Purpose of study

The main aim of this study is to investigate the percentage of backpack

weight to the students body weight, and to determine the relationship

between musculoskeletal symptoms and school backpacks carriage in

this regard in Tulkarm district schools (Elementary and Secondary

schools).

The specific objectives were:

To identify the methods of carrying school backpacks and method of

transport to arrive to school by elementary and secondary schools'

students for males and females.

To measure mean backpack weight and backpack weight to student's

weight ratio among elementary and secondary schools' students for

males and females.
 20

Describe self reported pain related to backpack use and evaluate the

relationship between self reported pain and backpack weight in

reference to students weight, also to study the duration of backpack use

and posture when wearing a backpack for elementary and secondary

schools children.
 21

CHAPTER TWO
LITERATURE REVIEW
 22
CHAPTER TWO
LITERATURE REVIEW

2.1 International Studies

In recent years, the media coverage as well as literature on backpack

use in schoolchildren has increased around the world. This is mainly

because there has been an increase in the size and weight of bags carried by

schoolchildren and a change in school curriculums. These factors

contribute to the anecdotal evidence of bodily pain in these children. In

recent years, scientific literature in this field has increased its focus on
childhood bodily pain, the type of school bag, the manner in which it is

carried, its weight, and the duration of carriage, all of which can affect the

cervical and shoulder posture of schoolchildren.

The loads carried by children to and from school have been the

subject of recent attention (18, 19, 20,27,60,28,29). Wiersema et al., in 2003 found

that children who carried a school bag that is more than 20% of their body

weight were at an increased risk of (LBP) Low Back Pain ; therefore,

(21)
requiring a visit to a physician . Moreover, it increased risk for LBP,

which lead to absence from school and sport for those children who carried

their bag in one hand rather than on the shoulder harness (22)(23).

Grimmer et al., in 2000 also found positive association between

longer periods spent carrying backpacks and LBP. Statistics showed that
two thirds of the 1269 high school students included in the study stated

they wore their backpacks over two shoulders (23).

 23

Pascoe et al., in 1997 reported that 11-13 years old students carried

school bag weighting 17% of body weight had detrimental effects to the
(24)
childs physical abilities . The researchers considered the effect of
carrying a school bag on posture and gait of 11-13 year old children and

found that carrying a school bag decreases stride length, increases stride

frequency and encourages a forward lean of the trunk. In the same study,

73.4% of children used only one strap of their school bags to carry material
(24)
and their books . One-strap bags seemed to encourage lateral spinal

bending and shoulder elevation, while two straps backpack reduced these

but significantly increased bending forward leaning of the head and

trunk(24).

Negrini et al., in 1999 measured the weight of backpacks of

schoolchildren and found that the mean school bag weight was 9.3 kg with

a maximum of 12.5 kg. (i.e. 22% of the body weight of the students
(25)
investigated) . Furthermore, 34% of the children carried more than 30%
of their body weight for at least one week. A decrease in the load carried is

advisable because the rates of LBP in children are approaching those seen

in adult (25).

Whittfield et al., in 2001 found the mean weight of school bag to be

6.6 kg and the mean relative school bag weight to be 11.7 % of body

weight (13.2% for third- form students and 10.3% for sixth form

students)(26). Most students used backpacks to transport their supplies, and

these were predominantly carried on two shoulders. Heavy schoolbags,

 24

long carriage durations and lack of access to lockers amongst third formers

could contribute to the production or maintenance of musculoskeletal

symptoms (26).

A study in Australia by Chansirinukor et al.,in 2001 examined the

posture of 13 Australian high school students under the following load

conditions: posture without a backpack, while carrying the bag on both

shoulders, carrying the bag on the right shoulder only, a bag weighing 15%

of the students body weight, and after walking for 5 minutes. Results

revealed that both backpack weight and time carried influenced cervical
(30)
and shoulder posture . Forward head posture increased when carrying a

backpack, especially one with a heavy load. Carrying a backpack weighing

15% of body weight appeared to be too heavy to maintain standing posture

for adolescents. In addition, this negatively affects the adolescent spine as it

continues growing in periodic spurts until the age of 18 (30).

Moreover, Dockrell et al ., investigated the mean weight of school

bags and effects of school bag carriage on the first year secondary students.

The mean school bag weight was 6.2 kg and the mean percentage body

weight carried in school bags was 12%, the level of reported discomfort

was high, and the discomfort was mostly reported to be in the shoulder

region followed to lesser degree by discomfort in the back (31). In addition,

Casey et al ., in 1996 have studied the weight of school bag, method of

load carriage and distance of load carriage. The results showed that
 25

students carried 15.2% of total body weight and 62% carried the bags on

their back (32).

Whittifield et al ., in 2005 conducted study investigate the weight of

school bag and prevalence of musculoskeletal symptoms among student in

third and sixth- form with mean age between 13.6-17.1 years and school
(33).
bag weight range from 13.2%-10.3% of their body weight respectively

These weights may exceed the recommended guideline load weight limits.

The study showed a very high self reported prevalence of

musculoskeletal symptom. Amongst this group of students, about 77.1 % of

them as well as the author believed that musculoskeletal symptoms were

multifactor in origin. The carriage of heavy school bag was suspected to be

a contributory factor (33).

Siambanes et al., in 2004 investigated the influence of the school

backpack on adolescent back pain. They found the mean average of

backpack weight to be 10.6 pounds (4.5 Kg) and the ratio of backpack

weight to students weight range from 3 to 43.42%, with a median of

8.84%. The result of this study showed nonspecific mechanical back pain

to be highly prevalent, and the reported severity and chronicity of pain

(34)
were high . Controlling for age, socioeconomic status, walking to and

from school, and method of wear results indicated that backpack weight,

measured as a percentage of body weight, was effective in predicting back

pain (P < 0.01) (34). Girls and those who walk to and from school were more

likely to report pain (P < 0.01). The method of wear, socioeconomic status,
 26

and age were not found to be significantly related to the prevalence of back
pain (34).

Mackie et al ., in 2005 showed that the manipulation of backpack

weight, hip-belt use, and shoulder strap length had a strong effect on

shoulder strap tension and shoulder pressure. Backpack weight had the

greatest influence on shoulder strap tension and shoulder pressure. Whereas

hip-belt use and then shoulder strap adjustment had the next greatest effects
(35)
. As a result, school students should wear their backpacks with the least

weight possible, use the hip-belt if present, allow a reasonable amount of

looseness in the shoulder straps and should position the heaviest items

closest to their back (35).

Hong et al ., in 2003 studied the effect of loads carriage on posture

during stair walking and found that when the load is 10% or greater of the

body weight, it induced greater trunk-forward inclination in subjects

ascending stairs, whereas athletic bags were found to cause greater trunk
(36)
range of motion than backpack during stair descent . Lai et al., in 2001

demonstrated restrictive effect on lung volumes when school-bag load is

heavier than 10% of childs body weight and found the detrimental effect

of a kyphotic posture on pulmonary mechanics and the necessity for health-

care professionals to advocate proper postural advice to schoolchildren,

teachers and parents (37).

Negiri et al., in 2007 investigated the postural effect of load on the

spine, it found that both types of load (symmetrical and asymmetrical)

 27

induced changes in children's posture (38). Skoffer et al., in 2007 found that

carrying the school bag in an asymmetric manner played a role in

(39)
occurrence of low back pain . Study by Sheir-Neiss et al., in 2003
emphasized the association of backpack use and back pain in adolescent

aged between 12-18 years. They found the use of backpacks during the

school day and backpack weights were independently associated with back

pain (40).

Grimmer et al., in 1999, the researchers examining the effect of

backpack weight on adolescent head on neck posture showed a significant

change in cranio-vertebral angle that was found at every year level, when

comparing standing posture with no backpack with posture when carrying a

backpack. This change appeared greatest for the youngest students (41).

Korvessis et al ., in 2005 investigated the influence of backpacks on

spinal curves, shoulder level, trunk alignment and back pain in adolescent,

the result showed that girls suffered from Dorsal Pain (DP) more often and
of much more intensity than boys . They also suffered from a decrease in

the angle known as Cranio-Cervical angel (CCA) and a shoulder and upper

trunk shift (42). Asymmetrically backpack carrying was associated with high

intensity of back pain. Symmetric backpack carrying was highly

(42)
recommended . Navuluri et al ., in 2006 found that the correlation

between pain and backpack weight per body mass index among girls was

positive and significant, but negative and non-significant among boys (43).
 28

In addition, Petronell et al., in 2006 found that carrying school bag

may have an effect on the developing spine the results shows deviations

posture in the lateral and posterior area (44).

The "Italian Backpack Study" tried to investigate schoolchildren's

subjective perceptions of their daily backpack loads to ascertain whether an

association exists between these sensations or the load itself and back pain,

and to identify the school, family, and personal factors that determine the

backpack load. Of the participants, 79.1% felt that their bags were too
heavy, 65.7% reported fatigue, and 46.1% complained of back pain (45) .

Back pain was associated with feeling of fatigue during carrying of

the bag and the amount of time spent carrying the bag more than the weight
of the bag. Researchers found that daily backpack carrying is a frequent
(45).
cause of discomfort for schoolchildren Moreover, there was an
association between this load and back pain, as a result, (schools, parents,
students) bear responsibility for the load carried, and all should modify
current behavior to reduce the stress of the bags on students. Suggestions
include having teachers take into consideration the weight of the difference
subjects, not only in terms of their intellectual content, but also in terms of
the load they place on the shoulders of their students, to prevent students
from carrying multiple heavy texts one night, and a very light bag the next.
The researchers also recommend that parents monitor what their children
carry to school each day (45). There are also some reports of other problems
associated with backpack i.e. functional scoliosis, rucksack palsy and
reduced lung functions. (46, 47).
 29

The 10% cutoff was recommended, along with a variety of practical

methods to help schools achieve that goal for middle and high school

students (48).

Skagg et al., in 2006 founded 37% of children aged between 11-14

years old to have back pain that was associated with use of a heavier back

pack (P = 0.001). This study identified two factors associated with self-

reported back pain in early adolescents that are amenable to change:

availability of school lockers and lighter backpacks (49).

Goodgold et al., in 2002 related backpack use with incidence of back

pain in children, researchers found that younger children carried

proportionally greater backpack loads. Fifty-five percent of all subjects

carried a load greater than 15% of their body weight (50).

Recent studies by Haselgrove et al., in 2008 connected the school

bag load with spinal pain in adolescent. The researchers found the

prevalence of back and neck pain to be approximately 50%; 53% of female

reported neck pain compared with 44% of males (P < 0.01) and almost half

of participants carried their school bag for more than 30 minutes per day

with 85% carrying their bag over both shoulders (51). School bags were felt

to be heavy by 54% and cause fatigue by 51%. Carrying a school bag for

more than 30 minutes daily and taking an inactive form of transport to

school ( car or bus) increased odds of having both back (OR 1.40, 95% CI
1.08 to 1.82) and neck pain (OR 1.47, 95% CI 1.13 to 1.19) (51).
 30

Macias et al., in 2008 showed how much pressure did the backpack
(52)
straps had over both shoulders . The researchers found pressure at 10%,

20%, and 30% of bag weight loads on both shoulders during low-back or
high back conditions; these were higher than the pressure threshold

(approximately 30 mm hg) to occlude skin blood flow. In addition,

asymmetry and high pressure exerted for extended periods may help

explain the shoulder and back pain attributed to back packs (52).

More recent study by Ramprasad et al., in 2010 investigated the

effect of Backpack weight in postural angle. The researchers compared the

postural angles with no backpacks and with backpacks weighting 5% to

25% of the subject body weight. The results showed the CV angle to
(53)
change significantly after 15% of backpack load (P < 0.05) . The HON
and HNOT angles changed significantly after 10% of Backpack load

(p<0.05) The Trunk and lower limb angle also changed significantly after

5% of backpack load (P < 0.05). Preadolescent children who carried a

backpack weighing 15% of their body weight had changes in all their

postural angles (53).

Brackley et al., in 2009 was conducted to evaluate the changes in

children trunk forward lean (TFL), cranio-vertebral angle (CVA), and

spinal lordosis angle (LA) that occurred with high, medium and low load
(54)
placement during standing and walking . The results of this study

indicated that significant changes occurred in (TFL) and (CVA) when the

backpack was loaded to 15% of the body weight, the researchers found that
 31

the low load placement in the backpack produce a fewer change in CVA

and LA (54).

Studies in 2008-2009 recommend and emphasized that the backpack

load should be limited to 10% of body weight because an increases to 15%

to 20% may lead to posture change, heart rate change, and lower limb

dynamics change for children while walking (55,56, 57).

In a more recent study in by Neuschwander et al., in 2010 concluded

that backpack loads were responsible for a significant amount of back pain

in children, which in part, may be due to changes in lumbar disc height or

curvature. This was the first upright MRI study to document reduced disc

height and greater lumbar asymmetry for common backpack loads in

children (58).

Chow et al .,in 2010 the researcher analyzed the change of spinal

curvature and repositioning error when carrying a backpack loaded at 15%
of body weight at different CG (center gravity) location anterior or
posterior at (T7, T12 or L3) in school children (59).

The researchers found both spinal curvature and repositioning error

were affected by backpack anterior posterior position- and CG level.
Results suggested that alternative carriage by changing the backpack
position occasionally between anterior and posterior positions might help to
relieve the effect of backpack on spine (59).

In Malaysian in 2007, the researchers investigated the change in

Ground Reaction forces (GRF) and trunk inclination among primary

 32

students when carrying heavy backpacks on boys aged between 9-11 years

old. It was found that significant differences in GRF occurred at loads of

20% of body weight and significant differences in trunk inclination of the

students when carrying heavy school bag more than 15% of body weight.

The researcher demonstrated the backpack should not exceed 15% of body

weight (61).

Puckree et al 2004 ., in South Africa studied the relationship

between pain and school bag by carriage in students aged between 11-14

years. It was found that shoulder and other bodily pains that were
experienced by the sample of scholars were strongly related to the type of

bag and the gender of the children. Although the weight carried did not
(62)
exceeds 10% of body weight yet there was increase in pain .In a study
conducted in Saudi Arabia, they investigated the percentage of body weight

represented by school backpack and the researchers recommended that the

school bag limit not to be more than 5-10% of student body weight (63).

2.2 Regional Studies

Locally, Al Fageeh etal., in 2009 investigated the relationship

between the load weight ratio of a schoolchild with lung vital capacity,

potential back pain, and postural problem. The researcher found

statistically significant correlation between extra load weight ratio and less

vital capacity, less of motion in flexion, extension, and left and right lateral
bending. Moreover, positive relationship was found between back pain and

extra load weigh ratio (64).

 33

CHAPTER THREE
METHODOLOGY
 34
CHAPTER THREE
METHODOLOGY

3.1 Study Design

This is a cross-sectional study conducted on healthy male and female

students aged 8-15 years old from third to ninth grade in elementary and

secondary schools. It was conducted between March and April of 2009.

The selection of students was randomly done from those who attended

Tulkarm governmental Schools. For the sake of a comprehensive study,

Tulkarm district was divided into four regions as follows:

1. Al-Sh`araweyeh.

2. Al-kafreyat.

3. Wadi-Alashaer.

4. The city and suburbs.

Appropriate schools were selected in coordination with Directorate

of Education; one males and one females in each of Al-Sh`araweyeh, Al-

kafreyat, and Wadi-Alashaer and eight schools from the city and its

suburbs (Four female and four male schools).

Five students were selected from each class. After that, the students

were interviewed by the researcher during the school days (Sunday -

Thursday). Subsequently, data collection was done during the interviewing

period.
 35

Data collection was accomplished through two steps:

First step

The height of each student was measured by a portable height

measurement scale. The body weight of each student was measured by
electronic scale (personal scale QE, 2003) and special electronic scale for
the weight of their school bag (empty* and full) in grams (e-Accura, SA13-
QT) respectively.

Second step

After recording the height of each student and weighting each

students body as well as weighting bags, each student was interviewed
alone in the laboratory room at school. This was done to answer a
questionnaire about the relation between the weight of the carried school
bag and musculoskeletal symptoms. This method was only used for grades
third, fourth, fifth and sixth because the student in elementary school needs
help to understand the information in the questionnaire, on average, the
interview time took approximately fifteen minutes for each student.
Students at secondary schools (seventh, eighth, and ninth grades)
completed the questionnaire themselves in about fifteen minutes.

3.2 Sampling

The total number of governmental students in Tulkarm district is

(65)
41,221 (20578 males and 20643 females) . The study population

*
Empty Bag just measured and no importance to calculate the significant value because it
similar for all calsses
 36

included students in the grade levels of third to ninth. The numbers of male

and female students in all governmental schools in Tulkarm district are

shown in table (3:1).

Table (3:1) The total numbers of students in the study population by

grade.
Grade Number of students
3rd 3304
4th 3307
5th 3405
6th 3399
7th 3518
8th 3560
9th 3623
Total number of student 24151

Initially, the sample size* was calculated as 2% of the total study

population (483 students). However, the researcher increased the number of

the selected students to 800 students because:

1- Increasing the sample number would increase the accuracy of scientific

research

2- The classes selected for study included more than one section in the

same grade.

*
S = 4z2 .p (1-p)/w2 Z)
Z=1.96 confidence interval 95%.
P= prevalence of problem among Palestine children 0.05.
W=confidence interval 20%.
 37
Table (3:2): The Distribution of Schools According To The Region.
Region Selected school # of Students
Zeta Boys school 36
Al-sh`araweiyh Attil girls School 80
(Elementary and secondary)
Kofor-Sor Boys school 40
Al-kafreat
Kofor-Sor Girls school 30
Bl`aa elementary and secondary 70
Wadi- Ashaer Boys School
Ramin Girls school 50
Kaled Ben S`aeed Boys school 70
Al-Hamdalla Boys School 50
al-kasse Girls school 60
The city and Mahmood Alhamshari Girls school 50
Suburbs Zanobia Girls school 50
Fatima Al- Zahra`a Girls School 54
Helmi Hanon Boys School 80
Abed Al-majed Thaih Boys School 50
The researcher took permission to visit the governmental school by
sending a letter from An-Najah University to the Directorate of
Education in Tulkarm. After that the researcher coordinated the schools
principals and supervisors to visit the selected schools.

The researcher selected two age groups:

A. Elementary age (6-12 years), most major developmental problems

have been identified. However, many problems are subtle and they
remain undetected until they undergo further development as children
enter the school environment. When this occurs, they begin to face
increased physical and mental demands. Numerous health, emotional,
and developmental problems can occur during this age span. (4).

B. Adolescents (13-18 years) are transitional from childhood to

adulthood. This period is characterized by many rapid physical,

 38

emotional, and sexual changes. In addition, it is imperative that this

age group succession meets numerous developmental tasks. These

challenging tasks and rapid succession of changes contribute to stress

related illness, dysfunctional family, interpersonal conflict, and

antisocial behavior (4).

3.3 Inclusion Criteria

1- Third to ninth grade students in participating schools conditioned to be

8-15 years old.

2- Male and female students.

3- Generally healthy students.

4- Students attending governmental Tulkarm districts schools.

5- Students with back pain.

3.4 Exclusion Criteria

The researcher excluded Students:

1- Not attending to governmental Tulkarm district schools.

2- Who are unable to stand on the weighting scale.

3- Who are not carrying or unable to carry school bag.

4- Who have disabilities and health problems.

5- Who are unable to provide data sufficiently.

 39

6- Above fifteen or below eight years old.

3.5 Questionnaire

A structural questionnaire that contains close-ended questions was

developed for this study.

The questionnaire contained two sections:

The first section contains personal details including age, gender, stages,
classes, residence, weight of student, weight of school bag; full and

empty, and height of student. In this section the researcher deleted the

question that related to their medical history (students who complaining

of disabilities) because it is not appropriate for this purpose of study.

The second section contains reproductive data that is used to assess the

effect of backpack on students back. This section contains eleven

questions pertaining to the use of the backpack and musculoskeletal

pain*. These questions are covered by the duration of carrying school

bag, method of travelling to school, and method of carrying school bag.

In the same section, the questions covered the** perceived load

(perceived weight and perceived fatigue) by asking the student if his /her

*
Musculoskeletal pain: is a common cause of both short and term disabilities (74) and affects
the bones, muscles, ligaments, tendons, and nerves. It can be acute (having a rapid onset with
severe symptoms) or chronic (long-lasting). Musculoskeletal pain can be localized in one area,
or widespread (75).
**
Perceived load in term means both weight and fatigue were strongly associated with back pain
(shoulder, Neck, lower back) (51).
 40

parents help in carrying back pack, if the student has fatigue* during

carrying the school bag, if he/she rests during that, and if he /she sways

right and left or bends forward while carrying the school bag for students in
the 3th,4th,5th grades the last question explained if he/she was repositioning

the bag while carrying it . There are also some questions of whether there is

back pain as they carry the backpack and where the site of the pain is.

Lifetime prevalence of back pain was identified by a question asking

whether the student had ever experienced back pain.

Calculation of Body Mass Index (BMI).

BMI was calculated as weight (in kg) divided by the square of height

(in meters). BMI was classified into three categories as follows (66):

1- Under weight <18.5.

2- Normal 18.5-25.

3- Over weight > 25.

Table (3:3): The Distribution of Students According To Body Mass

Index Groups.
Group Number of students Percentage%
<18.5 243 %30.4
18.5-25 468 %58.5
>25 89 %11.1
Total 800 %100.0

*
Fatigue: is probably the most common symptom of illness affecting suffers of most acute
and chronic conditions. Fatigue is also universal complaint that may sometimes be related
medical diagnosis or therapeutic treatments (76).
 41

Calculation of School bag weight as a percentage of body weight:

3.6 Research Questions

Q1. What is the percentage of weight carried by students in their school

backpacks to their bodyweight?

Q2. Is there a relationship between the weight of schoolbags and the

occurrence of neck, shoulder, and low back pain in students?

Q3.Does carrying a school bag affects students posture?

Q4. Is there a relationship (association) between ratio (bag weight to body

weight) with occurrence of fatigue and musculoskeletal symptoms?

Q5. Is there a relationship (association) between gender with occurrence

of fatigue and musculoskeletal symptoms?

Q6. Is there a relationship (association) between method of carrying

school bag with occurrence of fatigue and musculoskeletal symptoms?

Q7. Is there a relationship (association) between transportation with

occurrence of fatigue and musculoskeletal symptoms?

Q8. Is there a relationship (association) between time to arrive school with

occurrence of fatigue and musculoskeletal symptoms?

 42

Q9. Is there a relationship (association) between grade with occurrence of

fatigue and musculoskeletal symptoms?

Q10. Is there a relationship (association) between area of residence with

occurrence of fatigue and musculoskeletal?

3.7 Data Analysis

After collection, the data was entered into computer and analyzed
using SPSS (Statistical Package for Social Sciences) software, version16.
In addition to descriptive statistics (means, frequencies, etc), a multinomial
regression analysis was performed to investigate the association of certain
factors (gender, school bag carry method, bag weight to student weight
ratio, etc) on occurrence of musculoskeletal pain and fatigue during carry
of school bag. Odds ratios were obtained from the analysis and used to
compare the different levels of the same factor for relative risk of
occurrence of musculoskeletal pain and fatigue. All factors of interest were
simultaneously fitted in the regression model such that the effects of one
factor are adjusted for the effects of all the other factors in the model.

3.8 Ethical Consideration

A formal letter from An-Najah University was sent to the director

of Directorate of Education in Tulkarm district to give permission for the
researcher to conduct the study in the district schools.

Through contact with the students to collect data about backpack, the

researcher explained to them the importance and the objectives of the

 43

study. The researcher dealt privately with information that was taken from

each student.

3.9 Limitations of study

1. The difficulty of coordination with the selected schools because the

study was made at the same time of the school trips.

2. The difficulty of choosing students because of the midterm exam.

3. The teachers were on strike.

4. Some selected schools dont have the classes that the study needs.
 44

CHAPTER FOUR
RESULTS
 45
CHAPTER FOUR
RESULTS

4.1 Descriptive Analysis of the Study Sample.

Total number of students in this study was 800, including 371

females (46.4%) and 429 Males (53.6%). The number of students

according to educational stage was 409 (51.1%) in the elementary schools

and 391 (48.9%) in the secondary schools. 58% of students lived in the city

and suburbs and 42% lived in surrounding villages. The distribution of

students according to grade is shown in Table (4:1).

Table (4:1) Distribution of the students according to grade level.

Grade Number of students Percentage, %
3rd 101 12,6%
4th 101 12,6%
5th 97 12,1%
6th 111 13,9%
7th 137 17,1%
8th 124 15,5%
9th 129 16,1%
Total 800 100,0%

Table (4:2) shows the distribution of students according to the ratio

of school bag weight to the student weight. The results showed that 27% of

students usually carry school bag weighing < 10% of their body weight,

73% of students carry school bags weighing 10% or more of their body

weight (23% carry bags more than 15% of their body weight).
 46
Table (4:2): Distribution of students according to the ratio of school
bag weight to body weight
Ratio of school bag to Number of Percentage%
student weight Students
< 10% 216 27
10% and 15% 400 50
> 15% 184 23
Total 800 100

Half of the sampled students (50.6%) declared that school bag felt

heavy sometimes, while 42.1 % felt their school bag was always heavy

(only 7.2% did not feel that school bag was heavy). On the other hand,

38.4% of sampled students complained of always getting tiered while

carrying their school bag, 35.1% of students felt tired sometimes, (26.5%)

do not feel tired while carrying school bag. This indicates that a good

proportion of students spend intensive energy to carry the school bag

before arriving to school.

Figure (4:1) shows the method of transport to school by students.

Most of students (75%) walk to school, 18% use cars, 4.2% use the bus,

and about 2% of students use more than one method (e.g. walking + bus,

walking + car, walking + bicycle).

 47

Figure (4:1): Method of transport to arrive to school.

Figure (4:2) shows the time (in minutes) the students take to get to

school. Large proportion of students (65.7%) takes 5 to 15 minutes to get to

school and less than (5%) of students take more than 30 minutes to reach

school.

Figure (4:2): Time it takes students to get to school.

 48

Table (4:3) shows the number and percentages of students who

complained of pain (neck, shoulder and lower back) in general (during their

everyday life) and those who complained of pain (neck. shoulder. lower
back) while or after carrying school bag. The percentage of students who

complained of continuous (persistent) pain during everyday life was 8.8%

and 24.4% of students complained from non-persistent pain. Due to carry

of school bag the percentage of students complaining persistent pain

increased to 31.6% and the percentage of students who have non-persistent

pain increased to 37.9%. As we reported musculoskeletal pain 47.8% of

students had shoulder pain, 21.6% had lower back pain, and 18.2% had

neck pain.

Table (4:3): Distribution of students based on frequency of occurrence

of musculoskeletal pain in general and musculoskeletal pain due to
carrying school bag.
Occurrence of pain
None Sometimes Always
(%) (%) (%)
Pain in low back, neck, or 535 195 70
shoulder in everyday life. (66.9%) (24.4%) (8.8%)

Pain in low back, neck, or 244 303 253

shoulder while carrying (30.5%) (37.9%) (31.6%)
school bag.

Table (4:4) shows the distribution of students who sway right and

left, or bend forward while carrying school bag or repositioning the bag

because of it its weight. About 14% of the students always sway while

carrying the bag. This indicates that there is significant weight placed on

the back of students. Of all sampled students, 31.6% take a break for one to
 49

four minutes while carrying school bag (Figure 4:3). This indicates that the

weight of school bag is heavy and causes body fatigue to students.

Table (4:4): Distribution of the students according to their behavior

related to school bag.
NO Sometimes Yes
Sway left and right or bend 470 217 113
forward due to the weight of (58.8%) (27.1%) (14.1%)
school bag or repositioning the
bag.

Take a rest while carrying school 547 253

-----------
bag. (68.4%) (31.6%)

Parents help in carrying 36 764

(4.5%) -----------
School bag. (95.5%)

Figure (4:3): Rest time students take because of carrying school bag.

Most students (84.2%) carry their bags on both shoulders. Less than
12% carry bags on one shoulder, while about 4% alternate among one

shoulder, two shoulders or use wheel bag (Figure 4:3). Use other methods

to carry school bag

 50

Figure (4:4): Distribution of students according to the way they carry

school bag

Averages of student age, weight, height, BMI, bag weight and bag

weight to student weight ratio are presented in Table (4:5) by grade and

gender. The means increased with increasing class level.

 51

Table (4:5): Averages of student age, weight, height, BMI, bag weight (empty and full), and bag weight to student
weight ratio by grade and gender.
Student
Student Height of Bag weight Bag weight
# of Age (SD) weight \ bag
Class Gender weight (SD) student (SD) BMI (SD) Empty (SD) Full (SD)
Students (year) weight(Ratio)*
(Kg) (cm) (Kg) (Kg)
(SD)
M 64 8.45 (0.517) 30.328(5.666) 131.422(7.331) 17.346(2.537) 0.654(0.255) 4.040(0.635) 0.137(0.32)
3rd
F 37 8.54 (0.660) 30.951(8.334) 130.1081(6.131) 18.103(3.814) 0.669(0.283) 4.493(0.787) 0.151(0.036)
M 68 9.77 (0.536) 35.376(9.331) 136.757(6.309) 18.709(3.537) 0.612(0.221) 4.165(0.788) 0.122(0.277)
4th
F 33 9.67 (0.79) 32.512(6.592) 130.108(6.967) 17.300(2.144) 0.634(0.301) 4.539(0.855) 0.142(0.31)
M 40 10.66(0.614) 39.027(7.662) 141.400(6.417) 19.400(2.823) 0.660(0.285) 4.537(0.900) 0.124(0.033)
5th
F 57 10.43(0.521) 38.433(8.757) 141.114(8.292) 19.212(3.526) 0.624(0.217) 5.043(0.793) 0.137(0.036)
M 56 11.86(0.545) 42.770(10.489) 146.018(6.664) 19.906(3.933) 0.682(0.222) 5.079(1.139) 0.124(0.036)
6th
F 55 11.54(0.644) 43.435(12.270) 146.067(13.413) 21.831(1.712) 0.683(0.239) 5.208(0.727) 0.127(0.0322)
M 76 12.72(0.585) 47.593(11.825) 152.895(8.425) 20.152(3.668) 0.673(0.269) 5.564(1.243) 0.122(0.039)
7th
F 61 12.42(0.502) 48.613(10.040) 153.926(6.600) 20.463(3.806) 0.704(0.244) 5.546(0.843) 0.118(0.029)
M 62 13.69(0.436) 58.711(16.176) 161.556(8.839) 22.276(4.887) 0.704(0.230) 5.517(1.567) 0.100(0.040)
8th
F 62 13.54(0.538) 50.855(7.306) 156.605(5.906) 20.743(2.841) 0.632(0.238) 5.785(0.942) 0.115(0.025)
M 63 14.86(0.329) 62.119(17.055) 169.151(9.973) 21.680(5.675) 0.717(0.226) 7.217(1.616) 0.123(0.040)
9th
F 66 14.71(0.421) 56.253(12.116) 160.295(7.754) 21.864(4.367) 0.664(0.240) 6.053(1.050) 0.111(0.025)
* School bag weight \ Student weight = RESULT %
 52

4.2 Analytical findings

4.2.1 Factors Associated with Development of Musculoskeletal Pain

while Carrying School Bag

Table (4:6) shows the significance of the factors affecting occurrence

of the musculoskeletal pain while carrying school bag. The results showed
that grade, time to arrive to school, ratio of the bag weight to body weight,
and right-left swaying had significant relationships with occurrence of pain,
while residence, transport, and carry method had no significant relationship
(P > 0.10) with occurrence of pain. However, gender tended to be
significant (P = 0.061).

Table(4:6): Significance of factor effects on Occurrence of pain.

Walds Chi-
df P- Value
Square
Gender 3,521 1 0.061
Class 27,404 6 0.000
Residence 1,624 1 0.202
Transport 2,166 3 0.539
Carry Method 1,456 2 0.483
Time To Arrive School 14,412 4 0.006
Ratio 7,606 2 0.022
Right and Left swaying or
bending forward or 54,136 2 0.000
repositioning the bag

Table (4:7) shows relative risk of occurrence of musculoskeletal pain

for levels of factors from the multinomial regression analysis. Males had
lower risk than females (relative risk = 0.775, P = 0.061).

Comparison of grades, taking third grade as reference category,

showed that as grade got higher the risk of developing pain increased.
 53

Students in the ninth grade had 3.44 times higher risk of developing

musculoskeletal pain compared to third grade students (P << 0.001).

Table(4:7) Relative risk of various levels of the factors investigated for

relation with musculoskeletal pain while or after carrying school bag.
Factor Odds Ratio P-Value
Gender
Females Reference
Males 0.775 0.061
Grade
3rd Reference
4th 1.314 0.356
5th 1.881 0.031
6th 2.553 0.001
7th 2.886 0.000
8th 2.201 0.005
9th 3.435 0.000
Area of Residence
City Reference
Village 1.217 0.202
Transportation Method
Reference
Walk
0.733 0.363
Bus
1.099 0.623
Car
0.644 0.324
Other
Carry Method
One Shoulder
Reference
Two Shoulders
0.773 0.265
Other
0.680 0.350
Time Spent to Arrive The School
1-5 min
6-10 min Reference
1.209 0.430
11-15 min 0.041
16-30 min 1.657
2.262 0.004
>30 min 0.016
Ratio of bag weight to student weight 2.547
<10%
10%-15% Reference
1.214 0.277
>15%
1.790 0.007
Right Left swaying or Bending Forward
during carry of school bag
No Reference
sometimes 2.134 0.000
yes 4.777 0.000
 54

As time to school got longer, the risk of developing pain increased;

students who take 11-15 minutes to get to school had 1.657 times higher

risk compared to students who take less than 5 minutes (P = 0.04), those
who take 16-30 minutes to arrive to school had 2.262 times higher risk than

those who take less than 5 minutes (P =0.004), and students who take more

than 30 minutes to arrive to school had 2.547 times higher risk (P = 0.016).

However, there was no significant difference between students who

take 6-10 minutes and the reference category( RR = 1.209, P = 0.430).

Students who carry school bags weighing more than 15% of their
weight had significantly higher risk of developing musculoskeletal pain

than students carrying bags weighing less than 10% of their body weight

(RR = 1.79, P = 0.007). However, there was no significant difference in

risk of developing musculoskeletal pain between students carrying bags 10-

15% of their weight relative to students carrying bags less than 10% of

their body weight (RR=1.214, PP = 0.277).

Swaying left and right or bending forward or repositioning bags were

highly associated with the development of musculoskeletal pain. As shown

in Table (4:7), students who sometimes sway left and right or bend forward

while carrying school bag had 2.13 times higher risk compared to students

who never sway or bend forward (P = 0.000), while students who always

sway left and right or bend forward during carrying the school bag had
4.777 times higher risk compared to students who never sway or bend

forward (P = 0.000).
 55

4.2.2 Factors Associated with occurrence of fatigue while carrying

school bag

Table (4:8) shows the significance of the factors affecting occurrence

of fatigue while carrying school bag. The results showed that gender,

grade, time to arrive to school, ratio of bag weight to body weight, carry

method and right-left swaying were significantly associated (P <<0.05)

with occurrence of fatigue, while area of residence and transport had no

significant relationships (P > 0.10) with occurrence of fatigue.

Table(4:8): Significance (P values) of factor effects on occurrence of

fatigue while carrying school bag.
Walds Chi-
df P -Value
Square
Gender 9.153 1 0.002
Class 36.368 6 0.000
Residence .909 1 0.340
Transport 2.910 3 0.406
Carry method 9.042 2 0.011
Time to arrive to school 23.988 4 0.000
Ratio 11.497 2 0.003
Right and Left swaying
or bending forward or 121.100 2 0.000
repositioning the bag

Table (4:9) shows the relative risk of occurrence of fatigue while

carrying school bag. Males had lower risk than females (relative risk =
0.641. P = 0.002). As grade got higher, the risk of developing pain

increased. For example, Students in the ninth grade had 3.327 times higher

risk of developing musculoskeletal pain compared to third grade students

(P << 0.001).
 56

Comparison of carry methods, showed that students who carry their

school bags on one shoulder had higher risk of feeling fatigue than those

who carry their bags on two shoulders (P = 0.005). As the time to get to
school got longer the risk of feeling fatigue increased. Students who take 6-

10 minutes to get to school had 1.78 times higher risk relative to students

who take less than 5 minutes (P = 0.015). Those who take 11-15 minutes

had 2.451 times higher risk (P = 0.000). Students who take 16-30 minutes

to arrive to school had 3.727 times higher risk (P = 0.000). And students

who take >30 minutes to arrive to school had 3.7 times higher risk than

those who take less than 5 minutes (P = 0.001).

Students who carry school bags of more than 10% of their body

weight had significantly higher risk (P < 0.05) of feeling tired than students
carrying bags weighing less than 10% of their body weight (RR of 1.516.

and 2.064 for students who carry school bags of 10%-15% and those who

carry bags >15% of their body weight. respectively).

Swaying left and right or bending forward was also highly associated

with fatigue. Students who sometimes sway left and right or bend forward

during carrying the school bag had 4.48 times higher risk of fatigue

compared to students who never sway or bend forward (P = 0.000). while

those who always sway left and right or bend forward while carrying

school bag had 7.915 times higher risk compared to students who never

sway or bend forward (P = 0.000).

 57
Table (4:9) Relative risk of various levels of the factors investigated for
relation with fatigue while carrying school bag.
Factor Odds Ratio P-Value
Gender
Females Reference
Males 0.641 0.002
Grade
3rd Reference
4th 0.929 0.790
5th 1.933 0.021
6th 1.959 0.015
7th 3.110 0.000
8th 1.967 0.015
9th 3.327 0.000

Area of residence
City Reference
Village 0.866 0.644
Method of transport
Walk Reference
Bus 1.180 0.635
Car 1.042 0.829
Others 0.551 0.111
Carry method
One shoulder Reference
Two shoulders 0.516 0.005
Other 0.853 0.710

Time spent to arrive to school

1-5 min Reference
6-10 min 1.780 0.015
11-15 min 2.451 0.000
16-30 min 3.727 0.000
> 30 min 3.788 0.001

Ratio of bag weight to student weight

< 10% Reference
10%-15% 1.516 0.018
> 15% 2.064 0.001

Right left swaying or bending forward

during carry school bag
No Reference
Sometimes 4.483 0.000
Yes 7.915 0.000
 58

CHAPTER FIVE
DISCUSSION,
CONCLOUSIONS and
RECOMMENDATIONS
 59
CHAPTER FIVE
DISCUSSION, CONCLOUSIONS and
RECOMMENDATIONS

5.1 Discussion

The interest of carrying backpacks, particularly with regards to

children, has dramatically increased in recent years. The aim of the present
study, one of the first in Palestine, was to investigate the influence of

certain factors on occurrence of fatigue and musculoskeletal pain, namely;

gender, school grade, residence, ratio of school bag weight to students

weight, method of carrying school bag, duration of carrying of school bag,

method of transportation to school, and right-left swaying or bending

forward. The results of this study showed that grade, time to arrive to

school, ratio and right-left swaying or bending forward or repositioning bag

were significantly associated (P < 0.05) with musculoskeletal pain, while

gender, carry method, residence area, and method of transport were not

associated (P > 0.05) with musculoskeletal pain (although the effect of

gender was close to significance, P = 0.06). On the other hand, the results

showed that gender, grade, time to arrive to school, ratio of school bag
weight to student weight, carry method, and right-left swaying, or bending

forward or repositioning bag were significantly associated (P <<0.05) with

occurrence of fatigue, while area of residence and transport had no

significant relationships (P > 0.05) with occurrence of fatigue.
 60

Weight of school bag

The mean weight of full school bags in the study was 5.27 kg. For

male students the mean was 5.19 kg and for female students it was 5.354.

For primary schools, it was 4.63 kg and for secondary schools it was 5.94
kg. The mean weight of school bags in our study was less than those found
(11, 25, 32, 40) (32)
by other studies . A study in New Zealand found that the

mean bag weight was 7.0 kg for third grade and 6.3 kg for sixth grade
compared to 4.21 and 5.14 kg for third and sixth grades in this study.

Although the age range is not comparable, yet another study on students
(40)
aged 12-18 years reported that the mean of bag weight was 8.3 kg . In
other studies, students with mean age of 11.6 years had bag weights

averaging about 9 kg (11, 25). The range of bag weights in our study was 2.44

10.10 kg. The larger bag weight found in this study may be explained by

the fact that some students bring more books to school in some days than

other days. The mean of school bag weight differed slightly according to

gender; boys carry a mean weight of 5.192 kg, compared to girls who carry

a mean weight of 5.354 kg. These findings are consistent with those of
(67)
another study where girls carried on average 0.25 kg heavier bags than
(31)
boys but differ from those found by another study where, on average,

boys carried heavier (3.1-11.3 kg ) schoolbags than girls (1.6-10.7kg).

As previously explained, the difference in bag weights on a day to

day basis was found to be a factor in determining the average school bag
weight. Also, the number of additional materials carried by the student is a
 61

factor. This is a reflection of the various demands on school children from

their schools. Also, there is another important reason for the heavy weight

of the school bag related to the increasing number of curricular school

books in recent years.

School bag weight as a percentage of body weight. The mean of

school bag weight as a percentage of body weight carried by students was
(26, 8, 40, 35, 32)
12. 36%. Other studies had similar findings . In contrast, other
(67, 69)
studies found lower percentages 8.2%, 8.84% , and 10% for students

in Saudi Arabia (63). Other studies found considerable higher percentages of

(25) (24)
body weight: 30% , 17% , 19% for fifth grade, 21% for sixth grade,

14% for seventh grade, and 15% for eighth grade (50).

In this study female students carried bags of greater percentage of

their body weights (average of 12.59 %) than male students (average of

12.16%). The average ratio of school bag weight to body weight

(percentage) was higher for primary school students (13.179%) than

secondary school students (11.506%). This is a critical finding which

means that primary school students, in spite of their smaller height and

weight, carry heavier school bags than secondary school students. This may

be due in part to the greater number of subjects taken at school by the

younger age group. This may also reflect the lack of experience and

inability of this age group in deciding the necessary books and supplies to

take to school, as well as the experience of family and teachers. This

implies the necessity of providing lockers for school students.

 62

The mean of school bag weight to body weight ratio in our study was

12.36%. 73% of students carried bag weights >10% or more of their body
(71)
weight. Some global associations ATOA and ACA , and global studies
(48, 70, 56, 63)
recommend that the ratio should not exceed 10% of body weight.

In this study there was significant relationship (P < 0.05) between ratio of

bag weight to student weight and musculoskeletal pain. Students carrying

bags exceeding 15% of their body weight had 1.79 times higher risk of pain

compared to students carrying 10% of their body weight.

School bag related to musculoskeletal pain.

In this study the results showed that the percentage of students who

complained of continuous (persistent) pain during everyday life was 8.8%,

and 24.4% of students complained from non-persistent pain. The

percentage of students who complained persistent pain increased to 31.6%

during carrying the school bag and increased to 37.9% for students who

had non-persistent pain. For pain related to school bag carrying, 47.8% of
students had shoulder pain, 21.6% had lower back pain, and 18.2% had

neck pain. These findings were consistent with other studies; a study held
(31)
in Dubline schools showed that the majority of discomfort (65%) was

reported in the shoulder region, followed by 30% reported in back. High

(68)
levels of discomfort were also reported by van Gent et al where 43.6%

of their subjects complained of neck and or shoulder pain. In Puckree et al

(62),
study 86.9% of their subjects reported pain in the areas of shoulder,

neck and back. Study in California also reported 64% of the students
 63

having back pain at some time, 41.3% felt this pain when carrying their

backpack, and almost all of them reported feeling relief upon taking off
(69)
their backpack . In New Zealand study, 77.1% of students reported
experiencing some type of musculoskeletal symptom which they felt may

be attributable to schoolbag carriage (33).

The results of this study showed that grade, time to arrive to school,

ratio of the bag weight to body weight had significant relationships with

occurrence of pain (P < 0.05), these results are compatible with other

studies that have reported a positive association between school bag weight
along with other school bag factors and reported MSD. In a study in South

Australian an association was found between school bag weight ratio and

reported LBP, and even stronger positive association between school bag
carriage duration and reported LBP, but the boys had shown stronger

positive association between school bag carriage and reported LBP than
(13)
girls . Significant associations (P < 0.01) were found between non-
specific back pain and carrying of school bag greater than 20% of body
(21)
weight, school bag carrying by hand, and walking to school . In North

America, a study found that school bag weight (odds ratio 1.98, P < 0.0001,
median 14.4%, range 1-41% of body weight) and duration of carriage were

associated with higher incidence of reported back pain in 12-18 year school
(40)
students . A cross-sectional study in California found that backpack

weight measured as a percentage of body weight was effective in predicting

back pain, in addition, girls and those who walked to and from school were

more likely to report back pain (p<0.01) ,the age and mode of carriage were
 64

(69)
not significantly related to the prevalence back pain . A study in South

Africa showed that shoulder pain and other body pains were strongly

related to the type of school bag worn and gender of the child (62). Another
study showed that back pain was associated with the use of heavy
(49)
backpacks (P = 0.001) . Along with these studies, a study conducted in

New Zealand showed that musculoskeletal symptoms were reported by

77% of the students. Symptoms were most prevalent in the neck, shoulder,

and upper and lower back. Although musculoskeletal symptoms are

believed to be of a multi factorial origin, carrying of heavy school bags is

suspected to be a contributing factor to musculoskeletal pain for secondary

(33)
school students . Another study is consistent with our study in that it

showed that heavier relative backpack weight was associated with upper
and mid back pain. It also showed that heavier relative backpack weight

was associated with decreased sport time in school, and greater chiropractic

utilization (48). The results of this study showed that 42.1% of students felt
that the school bag is always heavy, 31.6% took a rest while carrying the

school bag due to its weight and 38.4% of sampled students complained of

always getting tired while carrying school bag. The results showed that
gender, grade, time to arrive to school, ratio of bag weight to body weight,

carry method and right-left swaying or bending forward and repositioning

bag were significantly associated (P <<0.05) with occurrence of fatigue.

This indicates that a good proportion of students spend intensive energy to

carry the school bag before arriving to school.

 65

These indicators show that the school bag generally affects the health

of students; this is compatible with other studies showed that carrying

(46)
heavy school bags has an effect on cardiovascular effort , and also
(26)
develops musculoskeletal symptoms in students . 59% of students

reported discomfort due to carrying school bag The majority of discomfort

(65%) was reported in the shoulder region, followed by 30% reported in the

back (31) .

Probably, the most important factor in our study is that the student
swaying left and right or bending forward and repositioning bag because of
heavy bag weight was associated with increased the risk of
musculoskeletal pain and fatigue. I think this negatively affects the posture
of the student, especially because they are of the age when their
musculoskeletal system is still developing. This is supported by the results
of a study by Grimmer et al., in 1999 which showed a significant change in
(7)
the cranio-vertebral angle when carrying a heavy school bag . It also
alters the posture and gait of the students carrying heavy school bags (24).

Carrying a backpack weighing 15% of the body weight appeared to

(30)
be too heavy to maintain standing posture for adolescents . The 15%
load condition induced a significant increase in trunk forward lean and
prolonged blood pressure recovery time (70).

Another study by Ramprasad et al., in 2010 indicated that significant

changes occurred in TFL and CVA when the backpack was loaded to 15%
(54).
body weight Also, little change in temporal-spatial gait parameters was
noted during backpack use with loads limited to 15% body weight (53).
 66

Yet another study by Neuschwander et al., in 2010 used magnetic

resonance imaging (MRI) to examine the effect of backpacks on the

intervertebral discs. According to the results, backpacks alter the fluid

content of these discs, which is a risk factor for disc herniation and

osteoarthritis (58). Backpack carrying, particularly asymmetrically, results in

a shift of the upper trunk, shoulder and cervical lordosis, resulting in an

increase of back pain during school periods and holidays (42).

5.2 Conclusions

Our study involved a large cross sectional sample of students who

attended Tulkarm governmental schools. The main aims of our study were

to investigate the percentage of backpack weight to body weight, and to

determine the relationship between musculoskeletal symptoms and fatigue

during school backpack carriage. Results revealed that 73% of students

carry schoolbags weighing 10% or more of their body weight that exceeded

the approximate guide line of 10% body weight. Also, our results showed
the percentage of students who complained of continuous (persistent) pain

during everyday life was 8.8% and 24.4% of students complained from

non-persistent pain. Due to carrying school bag the percentage of students

complaining persistent pain increased to 31.6% and the percentage of

students who have non-persistent pain increased to 37.9%. As we reported

musculoskeletal pain 47.8% of students had shoulder pain, 21.6% had

lower back pain, and 18.2% had neck pain. Almost half of the sampled

students (50.6%) declared that school bag felt heavy sometimes, while 42.1
 67

% felt their school bag was always heavy. 38.4% of sampled students

complained of always getting tiered while carrying their school bag while

35.1% of students felt tired sometimes. The results showed that class level,
time to arrive to school; ratio of the bag weight to body weight, and right-

left swaying had significant relationships with occurrence of

musculoskeletal pain. The results show that gender, grade, time to arrive

to school, ratio of bag weight to body weight, carry method and right-left

swaying were significantly associated (P <<0.05) with occurrence of

fatigue. Future research work in schools is required to confirm these

results. In particular, longitudinal population studies on the risk factors for

musculoskeletal pain in secondary and elementary school students are

needed.

5.3 Recommendations

Overweight school bags will bring additional stress and fatigue to

primary and secondary students. As a physiotherapist worker and health

provider, I recommend that, as a precautionary measure, students should

avoid carrying school bags that exceed 10% of their body weight. Also, we

need the MOH and MOED to act promptly to solve this major health issue

starting with a National Plan to provide all students with Electronic book.

The following are some suggested measures for responsible people to take

in order to help students reduce the weight of their school bags hence

securing their health.

 68

1- Recommendations for Schools

Raise awareness of the issue.

Promote home/school cooperation on the issue.

Include back care in health education programs (Ergonomics awareness

and posture training).

Lockers for students to store and retrieve books and other items should

be installed where possible.

Encourage students to use school bags, pencil cases and other stationery

items that are made of durable but light-weight materials.

Schools should explain to parents the role they play in reducing the
weight of school bags.

2- Recommendations for Parents.

Parents should be urged to select school bags and items which are made

of light-weight materials.

Remind and help their children to pack school bags every day according

to the timetable.

Instead of carrying textbooks home, photocopy relevant chapters.

Regularly ask your child if their backpack is causing fatigue or pain.

See your doctor if your child complains of back pain.

3- Recommendations for authors of books.

Consider the weight of schoolbags when writing textbooks.

Coordinate with school communities in finding solutions.

 69

4- Recommendation for students and parents.

There are two guidelines for safe and proper backpack use that the

students take into account:

1-Choose it right

The size should be proportional to the size of the child.

Choose a back pack with padded shoulder straps that fits your childs
size.
Use the stabilizing waist strap around the waist and the child can use
that strap to stabilize the load and prevent injuries

2- Carry and lift it right.

Face the backpack and bend at the knees before you lift it.
Use both shoulder straps; make them comfortable but not too tight.

Adjust the shoulder straps so that the bottom of the backpack is just
above the childs waist.

Pack the heaviest items so they are closest to the childs back.
Make sure that items cant move around during transit.

Look for signs of pain. Such as, red marks from straps and poor
posture. This indicates if a backpack fits poorly or is overloaded.

All the above recommendations should be added to a comprehensive

school health-promotion. So, students in schools will be healthy and have
correct posture. for more details about recommendation see appendix (E).
 70
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:http://www.scienceiq.com/Facts/MyAchingBack.cfm

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http://www.ask.com/health/transcript/vpvideo/anatomy- of-the-spine.

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Myofasial pain Syndrome and the Fibromyalgia Syndrome.
Birger land, 1993; P 336.

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musculoskeletal_pain.aspx.

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Clinical Differentiation and Intervention. 2004; P 655
 79

Appendixes
 80
Appendix (A)
Arabic questionnaire

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 81

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 82
\ *
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30- 16 15 - 11 10- 5 5

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 83
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 84
Appendix (B)
English Questionnaire

An-Najah National University

Faculty of Graduate Studies

Public Health

Study about Influence of backpacks on students backs

1- Personal information:

*Age: years.

*Gender: male female

*Education level: preliminary secondary

*Grade: 3 grade 4grade 5grade

6grade 7grade 8grade 9grade

* Student weight Kg

*Weight of school bag: full Kg empty Kg

* Height of student: cm

* Do you have any previous medical problem such as fracture or surgery?

Yes No

2. Student and school bag.

*Do your parents help you carry your schoolbag?

Yes No
 85
How do you go to school?

Walking:
Yes No

Bus:
Yes No

Car:
Yes No

Bicycle:
Yes No

* How much time does it take to travel from home to school while carrying
the school bag?

5> minutes 5-10 minutes 11-15 minutes

16-30 minutes < 30 minute

*How do you carry your school bag?

On one shoulder
Yes No
On two shoulders
Yes No
By one hand
Yes No
By two hands
Yes No

* Kind of parents help such as (parents helps there to carry the bag on his shoulders, Parents
carrying cases their children until they reach school).

*Do you suffer from pain in your lower back, neck or shoulder in daily
life?

Yes No sometimes
 86
*Do you feel pain after or while carrying the school bag?

Yes No sometimes

If you answered yes or sometimes, do you feel that pain in the

Neck
Yes No

Shoulder
Yes No

Lower back
Yes No

* When you are carrying the school bag, do you sway left and right, or
bend forward or repositioning his /her bag as a result of weight?

Yes No Sometimes

Do you think your school bag is too heavy?*

Yes No Sometimes

Do you take a break from carrying the school bag while carrying it?*

Yes No

*How much time does this break take?

1minute 2minutes 5minutes or more

* Does carrying your bag make you tired?

Yes No Sometimes

Thanks for your Cooperation

 87
Appendix (C)
Relationship between two variables by using fisher exact test
Column variable
Row variable Gender Grade Class
Parents help child to N.S. (P > 0.05
N.S. N.S. P > 0.05
carry school bag (CI99%)
Transport Method (P < 0.01 CI N.S. (P > 0.05
N.S.
to school 99%) CI 99%)
Time spent carrying *** (P < 0.01 *** (P < 0.01
*** (CI 99%)
school bag CI 99%) CI 99%)
Student
complaining of pain *** (P<0.01 CI *** (P < 0.01
(CI 99%)
(Neck, shoulder, 99%) CI 99%)
low back) in general
Student
complaining of pain
(Neck, shoulder, *** (P < 0.01 *** (P < 0.01
***
low back) during or CI 99%) CI 99%)
after carrying
school bag.
Student complain of
neck pain during or ** (P < 0.01 CI
N.S. (P < 0.01)
after carrying 99%)
school bag
Student complain
shoulder pain N.S. (P > 0.05
** N.S. (P > 0.05)
during or after CI 99%)
carrying school bag
Student
complaining of low
*** (P < 0.01
back pain during or N.S. *** (P < 0.01 )
CI 99%)
after carrying
school bag
Student sawing
right and left or
** (P < 0.05 CI N.S. (P > 0.05
bending forward N.S.
99%) CI 99%)
due to school bag
weight
Student feeling
*** (P < 0.01 *** (P < 0.01
school bag too ***
CI 99%) CI 99%)
heavy
 88
Student taking a rest
*** (P < 0.01
time during carrying N.S. N.S. (P>0.05)
CI 99%)
school bag
Rest Time spent due
*** (P<0.01 CI *** (P < 0.01
to carrying school ***
99%) CI 99%)
bag
Student getting
*** (P < 0.05 *** (P < 0.01
tiered during ***
CI 99%) CI 99%)
carrying school bag
Student method in *** (P < 0.01 *** (P < 0.01
***
carrying school bag CI 99%) CI 99%)

N.S: Not significant (P>0.05).

** Significant relationship (P<0.05).

*** Strong significant relationship (P <0.01)

 89
Appendix (D)
Significant differences between the means through the use of
(T-test for equality means).
Dependant variable

independent Student Height BMI Bag Bag Bag

variable weight student Weight Weight Weight \
\Kg \Cm Empty Full Student
Weight
Gender P= 0.580 P=0.659 P=452 P=0.481 P=0.080 P=0.060
N.S N.S N.S N.S N.S ****
Grade P=0.000 P=0.000 P=0.000 P=0.076 P=0.000 P=0.000
*** *** *** N.S *** ***
Residence P=0.000 P=0.000 P=0.366 P=0.000 P=0.000 P=0.000
*** N.S *** *** ***
Parent help child to P=952 P=0.865 P=0.791 Non P=0.995 P=0.909
carry school bag N.S N.S N.S N.S N.S

Student complain P=0.874 P=0.002 P=0.880 Non P=0.003 P=0.655

neck pain N.S *** N.S *** N.S

Students complain P0.827 P=0.091 P=0.949 Non P=0.001 P=0.029

shoulder pain N.S N.S N.S *** **
during or after carry
school bag
Students complain P=0.000 P=0.000 P=0.390 Non P=0.000 P=0.518
low back pain *** N.S N.S *** N.S
during
Or after carry
school bag
Student taking rest P=0.112 P=0.658 P=0.078 Non P=0.578 P=0.046
during carry school N.S N.S **** N.S ***
bag

N.S = not significant.

** Significant relationship P <0.05.

*** Strong significant relationship P <0.01.

**** tended to be significant.

 90
Appendix (E)
Recommendations

Overweight school bags will bring additional stress and fatigue to

primary and secondary students. As a physiotherapist worker and health

provider, I recommend that, as a precautionary measure, students should

avoid carrying school bags that exceed 10% of their body weight. The

following are some suggested measures for responsible people to take in

order to help students reduce the weight of their school bags hence securing

their health.

1. Recommendations for Schools.

Raise awareness of the issue.

Promote home/school cooperation on the issue.

Include back care in health education programs.

Lockers for students to store and retrieve books and other items should

be installed where possible.

Encourage students to use school bags, pencil cases and other

stationery items that are made of durable but light-weight materials.

Demonstrate to students the correct manner and posture in carrying

school bags and explain the adverse effects that over-weight

schoolbags can have.

Encourage the students to store books in their school locker, and only

bring home those needed for homework.

 91

2. Recommendations for Parents.

Home-school cooperation is important to raise awareness of the issue

and to communicate with the school in finding solutions through:

Schools should explain to parents the role they play in reducing the

weight of school bags.

Parents should be urged to select school bags and items which are
made of light-weight materials.

Instead of carrying textbooks home, photocopy relevant chapters.

Discourage their children from bringing magazines, toys and

unnecessary items to school.

Remind and help their children to pack school bags every day

according to the timetable.

Regularly clean out the backpack, since your child may be storing

unneeded items.

Regularly ask your child if their backpack is causing fatigue or pain.

If so, lighten the load and adjust the fittings.

See your doctor if your child complains of back pain.

If your child insists they need to bring home more books than they

can comfortably carry, see their teacher.

3. Recommendations for authors of books.

Consider the weight of schoolbags when writing textbooks.

Coordinate with school communities in finding solutions.
 92

4. Recommendations for students and parents.

There are three guidelines for safe and proper backpack use that the

students take into account:

1-Choose it right

The size should be proportional to the size of the child. Looking at the

childs back, the height of the backpack should be no more than three
quarters of the length between the childs shoulder blades and waist.

Larger than that is too large for the child and invites the child to fill it

to capacity, which will exceed health and safety limits.

Choose a back pack with padded shoulder straps that fits your childs

size. (A backpack that's too large will bend forwards the buttocks,

stressing the child's lower back and shoulder. Look for backpacks that
have padded shoulder straps to prevent pinching nerves in and around

the shoulder and neck area.

Use the stabilizing waist strap around the waist and the child can use

that strap to stabilize the load and prevent injuries that occur when the

load swings wildly, taking the child with it.

2- Pack it right.

The backpack should weigh less than 10 percent of your childs body

weight for example, a child of 40 kg should carry less than 4kg in

their backpack. Ideally, the child in this example should only carry
around 23kg of books.
 93

Pack the heaviest items so they are closest to the childs back. If the

heaviest items are packed further away, this throws out the childs

centre of gravity and causes unnecessary back strain.

Make sure that items cant move around during transit, as this could
decentralize your childs centre of gravity.
Dont carry lots of equipment at the same time. Such as; sports gear,
musical instruments or art materials.

3- Carry and lift it right.

Face the backpack before you lift it.

Bend at the knees.
Using both hands, check the weight of the pack.
Lift with your legs, not your back
Carefully put one shoulder strap on at a time. Never sling the pack
onto one shoulder.
Use both shoulder straps; make them comfortable but not too tight.
Carrying the backpack on one shoulder, can cause long-term neck,
shoulder, back, and postural problems.
When taking off the backpack, slip an arm through one shoulder
strap, and then the other.
Look for signs of pain. Such as, red marks from straps and poor
posture. This indicates if a backpack fits poorly or is overloaded.

Adjust the shoulder straps so that the bottom of the backpack is just
above the childs waist dont allow them to wear the backpack
slung low over their buttocks.
 94

Your child should lift the backpack with a straight back, using their

thigh muscles. The backpack should be lifted with both hands and

held close to the body. When fitted correctly, the backpack should
form comfortably to the childs back, rather than hang off their

shoulders.

All the above recommendations should be added to a comprehensive

school health-promotion. So, students in schools will be healthy and have

correct posture.
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